Diversity by Race, Ethnicity, and Sex within the US Psychiatry Physician Workforce.

OBJECTIVE: This study assessed the distribution of race, ethnicity, and sex within the US psychiatry physician workforce and trends from 1987 to 2016. METHODS: The authors used physician workforce data to assess differences in race, ethnicity, and sex among psychiatric practicing physicians, faculty, fellows, residents, residency applicants, and medical graduate cohorts. Binomial tests were used for comparison between individual cohorts and to US population statistics. A simple linear regression model was used to assess trends among psychiatric residents and faculty over years 1987-2016. RESULTS: Within psychiatry, historically underrepresented minorities in medicine (URMs) had less representation as residents (16.2%), faculty (8.7%), and practicing physicians (10.4%) compared with the US population (32.6%), Ps < 0.0001. Females were underrepresented as psychiatric practicing physicians (38.5%, P < .0001). There was greater URM representation among residents (16.2%) compared with that of Psychiatry faculty and practicing physicians (Ps < .0001). Racial/ethnic representation did not differ significantly compared with subspecialty fellows; however, the addiction subspecialty contained the least URM and female diversity. Historical trends indicated the proportion of female faculty (0.9%/yr) increased nearly 1.5 times faster than that of female trainees (0.6%/year). Conversely, the proportion of URM residents (0.26%/year) increased over 4 times faster than that of URM faculty (0.06%/year), with black faculty actually decreasing in proportion. CONCLUSIONS: Female and URM representation within the psychiatry physician workforce is significantly lower than US population demographics; however, trends indicate diminishing underrepresentation. While psychiatry residency remains more diverse than other specialties, specific trends identify poor minority representation among psychiatry faculty and fellows as areas needing attention.

Delays in definitive cervical cancer treatment: An analysis of disparities and overall survival impact.

OBJECTIVE: Delays in time to treatment initiation (TTI) with definitive radiation therapy (RT) or chemotherapy and RT (CRT) for cervical cancer could lead to poorer outcomes. This study investigates disparities in TTI and the impact of TTI on overall survival (OS). METHODS: Adult women with non-metastatic cervical squamous cell carcinoma diagnosed between 2004 and 2014, treated with definitive RT or CRT, and reported to the National Cancer Database were included. TTI was defined as days from diagnosis to start of RT or CRT. The impact of TTI on OS in patients treated with concurrent CRT which included brachytherapy was then assessed. RESULTS: Overall, 14,924 patients were included (84.7% CRT, 15.3% RT). TTI was significantly longer for Non-Hispanic Black (NHB) (RR, 1.14; 95% CI, 1.11 to 1.18) and Hispanic women (RR, 1.19; 95% CI, 1.15 to 1.24) compared to Non-Hispanic White (NHW) women. Expected TTI (eTTI) for NHW, NHB, and Hispanic women were 38.1, 45.2, and 49.4days. eTTI rose from 36.2days in 2004 to 44.3days by 2014. Intensity-modulated radiation therapy (IMRT) was associated with increased eTTI of 46.5days versus 40.0days for non-IMRT. Longer TTI was not associated with inferior OS in patients treated with concurrent CRT. CONCLUSIONS: Delays in starting RT/CRT for cervical cancer increased from 2004 to 2014. Delays disproportionately affect NHB and Hispanic women. However, increased TTI was not associated with increased mortality for women receiving CRT. Further study of TTI's impact on other endpoints is warranted to determine if TTI represents an important quality indicator.

Burnout Among United States Orthopaedic Surgery Residents.

OBJECTIVE: There is growing interest in the problem of burnout among physicians. Here, we examine the factors associated with burnout in orthopedic surgical training. DESIGN: An Internet-based anonymous survey assessing workload, work-life balance, education, and resident-specific factors such as marital status and postgraduate year was developed. The survey was distributed to United States orthopedic surgery residency directors in September 2018, and program directors were asked to forward the survey to their trainees. Multivariable analysis assessed correlations with burnout. SETTING: All 161 Accreditation Council for Graduate Medical Education (ACGME)-accredited United States orthopedic surgery residency programs. PARTICIPANTS: Two hundred and three United States orthopedic surgery residents. RESULTS: Thirty-eight percent of respondents reported symptoms of burnout. Even so, the vast majority did not regret choosing a medical career (95%) or their choice of residency program (90%). Greater than half of trainees who responded reported educational debt over $200,000. Thirteen percent reported receiving verbal abuse from faculty more than rarely. On multivariable analysis, 3 factors emerged that were associated with higher burnout: working more than 80 hours per week (odds ratio [OR] 2.8; range, 1.1-7.8), use of electronic medical record more than 20 hours per week (OR 2.1; range 1.0-4.5), and receiving verbal abuse from faculty more than rarely (OR 3.7; range, 1.3-11.5). The perception of adequate nursing support was associated with lower burnout (OR 0.2; range, 0.04-0.5). CONCLUSIONS: More than one-third of orthopedic trainees are experiencing burnout, but most still maintain high levels of career satisfaction. The key factors strongly associated with resident burnout are modifiable. Targeted interventions related to these factors should be evaluated for their potential to reduce burnout in orthopedic surgery residents. CLINICAL RELEVANCE: Strategies to reduce the development of burnout have the potential to improve quality of care and decrease medical errors.

Impact of radiotherapy duration on overall survival in squamous cell carcinoma of the anus.

BACKGROUND: Prolongation of radiotherapy (RT) in the treatment of numerous types of cancer has been shown to reduce overall survival (OS). Treatment delays are common in squamous cell carcinoma of the anus (SCCA) due to the toxicity of definitive chemoradiation (CRT). The effect of these delays on outcomes has not been well evaluated. This study investigated the effects of RT prolongation on OS in patients receiving CRT for SCCA. METHODS: The National Cancer Database was queried for adult patients diagnosed with SCCA and treated with CRT from 2004-2014. Cox proportional hazard regression models examined the effect of duration of RT, measured as fractions delivered per week, on OS. Negative binomial regression assessed the effects of demographic and prognostic factors on the duration of RT. RESULTS: A total of 8,948 patients were included in the analysis of factors impacting treatment duration, and 6,429 patients in the OS analysis. Multivariable analysis (MVA) showed female gender, non-private insurance, treatment at a low or intermediate volume facility, Charlson/Deyo score ≥2, and advanced disease were associated with longer RT duration. Treatment with IMRT, with single agent chemotherapy, at an academic center, and in later years were associated with shorter RT duration. A decrease in fractions delivered per week was independently associated with reduced OS with a cutoff of 4.72 fractions per week (about 2 missed fractions over a 30 fraction treatment) delineating the largest differences in OS. CONCLUSIONS: Efforts should be made to avoid RT interruptions of any length in SCCA patients and to compensate for treatment breaks to reduce the total duration of RT.

Socioeconomic Factors Associated With Burnout Among Oncology Trainees.

PURPOSE: Burnout in the medical workforce leads to early retirement, absenteeism, career changes, financial losses for medical institutions, and adverse outcomes for patients. Recent literature has explored burnout in different specialties of medicine. This article examines burnout among medical oncology trainees and identifies factors associated with burnout and professional dissatisfaction, including socioeconomic factors. METHODS: US medical oncology programs were sent a survey that included the Maslach Burnout Index-Human Services Survey as well as demographic, socioeconomic, and program-specific questions tailored to medical oncology fellowship. Primary binary end points included burnout, satisfaction with being a physician, and satisfaction with being a medical oncologist. Binomial logistic models determined associations between various characteristics and end points. RESULTS: Overall, 261 US fellows completed the survey. Seventy percent of international medical graduates reported no educational debt, whereas only 36% of US graduates reported no educational debt. Eighty-two percent of survey respondents reported their mother had at least a bachelor's degree, and 87% of respondents reported their father had at least a bachelor's degree. At least 27% of respondents had symptoms of burnout. Factors inversely associated with burnout on multivariable analysis included having a mother who graduated college (odds ratio [OR], 0.27), reporting an adequate perceived balance between work and personal life (OR, 0.22), feeling that faculty care about educational success (OR, 0.16), and being in the final year of training (OR, 0.45). Having debt ≥ $150,000 (OR, 2.14) was directly associated with burnout. CONCLUSION: Symptoms of burnout are common among medical oncology fellows and are associated with educational debt and socioeconomic factors.

I Can't Breathe: The Continued Disproportionate Exclusion of Black Physicians in the United States Radiation Oncology Workforce.

PURPOSE: Black physicians remain disproportionately underrepresented in certain medical specialties, yet comprehensive assessments in radiation oncology (RO) are lacking. Our purpose was to report current and historical representation trends for Black physicians in the US RO workforce. METHODS AND MATERIALS: Public registries were used to assess significant differences in 2016 representation for US vs RO Black academic full-time faculty, residents, and applicants. Historical changes from 1970 to 2016 were reported descriptively. Linear regression was used to assess significant changes for Black residents and faculty from 1995 to 2016. RESULTS: In 2016, Black people represented 3.2% vs 1.5% (P < .001), 5.6% vs 3.2% (P = .005), and 6.5% vs 5.4% (P = .352) of US vs RO faculty, residents, and applicants, respectively. Although RO residents nearly doubled from 374 (1974) to 720 (2016), Black residents peaked at 31 in 1984 (5.9%; 31 of 522) and fell to 23 (3.2%; 23 of 720) in 2016 across 91 accredited programs; Black US graduate medical education trainees nearly doubled over the same period: 3506 (1984) to 6905 (2016). From 1995 to 2016, Black US resident representation significantly increased by 0.03%/y, but decreased significantly in RO by -0.20%/y before 2006 and did not change significantly thereafter. Over the same period, Black US faculty representation significantly increased by 0.02%/y, whereas Black RO faculty significantly increased by 0.07%/y before 2006, then decreased significantly by -0.16%/y thereafter. The number of Black RO faculty peaked at 37 in 2006 (3.1%; 37 of 1203) and was 27 (1.5%; 27 of 1769) in 2016, despite the nearly 1.5-fold increase in the number of both RO faculty and Black US faculty overall (4169 in 2006 and 6047 in 2016) during that period. CONCLUSIONS: Black physicians remain disproportionately underrepresented in RO despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand barriers to specialty training and inclusion, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the RO physician workforce.

Industry Funding Is Correlated With Publication Productivity of US Academic Radiation Oncologists.

PURPOSE: Industry payments to physicians are financial conflicts of interest and may influence research findings and medical decisions. We aim to (1) characterize industry payments within radiation oncology; and (2) explore the potential correlation between receiving disclosed industry payments and academic productivity. MATERIALS/METHODS: CMS database was used to extract 2015 industry payments. For academic radiation oncologists, research productivity was characterized by h- and m-indices, as well as receipt of National Institutes of Health (NIH) funding, which is not an industry payment. Logistic regression models were used to determine whether publication metrics (m-index, h-index) and other study characteristics such as gender, PhD status, NIH institution funding status, were associated with the endpoints, research and general payments. Associations between the amount of payments (if any) and publication metrics were further studied using linear regression models. RESULTS: A total of 22,543 individual payments totaling $25,532,482 to 2,995 radiation oncologists were included. Among the 1,189 academic radiation oncologists, 75% received less than $167; on the other hand, 10 (<1%) individuals received $6,425,728 (51%) of payments. On multiple logistic regression, research payments were significantly associated with the m-index, odds ratio 2.86 (95% confidence interval, 1.84-4.45, p-value <0.0001); as well as with the h-index, odds ratio 1.03 (95% confidence interval, 1.01-1.05, p-value <0.0001). The linear regression model shows that both m-index and h-index were significantly positively associated with the amount of general payments (p-values <0.0001). CONCLUSION: There is an association between disclosed payment from the industry and increased individual research productivity metrics. Further research to find the cause behind this association is warranted.

International Medical Graduates in the US Physician Workforce and Graduate Medical Education: Current and Historical Trends.

BACKGROUND: Data show that international medical graduates (IMGs), both US and foreign born, are more likely to enter primary care specialties and practice in underserved areas. Comprehensive assessments of representation trends for IMGs in the US physician workforce are limited. OBJECTIVE: We reported current and historical representation trends for IMGs in the graduate medical education (GME) training pool and US practicing physician workforce. METHODS: We compared representation for the total GME and active practicing physician pools with the 20 largest residency specialties. A 2-sided test was used for comparison, with P < .001 considered significant. To assess significant increases in IMG GME trainee representation for the total pool and each of the specialties from 1990-2015, the slope was estimated using simple linear regression. RESULTS: IMGs showed significantly greater representation among active practicing physicians in 4 specialties: internal medicine (39%), neurology (31%), psychiatry (30%), and pediatrics (25%). IMGs in GME showed significantly greater representation in 5 specialties: pathology (39%), internal medicine (39%), neurology (36%), family medicine (32%), and psychiatry (31%; all P < .001). Over the past quarter century, IMG representation in GME has increased by 0.2% per year in the total GME pool, and 1.1% per year for family medicine, 0.5% for obstetrics and gynecology and general surgery, and 0.3% for internal medicine. CONCLUSIONS: IMGs make up nearly a quarter of the total GME pool and practicing physician workforce, with a disproportionate share, and larger increases over our study period in certain specialties.

Resident satisfaction with radiation oncology training.

PURPOSE: Residency training environments can differ significantly; therefore, resident satisfaction may vary widely among programs. Here, we sought to examine several variables in program satisfaction through a survey of radiation oncology (RO) trainees in the United States. METHODS AND MATERIALS: An anonymous, institutional review board-approved, internet-based survey was developed and distributed to U.S. residents in RO in September 2016. This email-based survey assessed program-specific factors with regard to workload, work-life balance, and education as well as resident-specific factors such as marital status and postgraduate year. Binomial multivariable regression assessed the correlations between these factors and the endpoint of resident-reported likelihood of selecting an alternative RO residency program if given the choice again. RESULTS: A total of 215 residents completed the required survey sections, representing 29.3% of U.S. RO residents. When asked whether residency allowed for an adequate balance between work and personal life, the majority of residents (75.6%) agreed or strongly agreed, but a minority (9.3%) did not feel that residency allowed for sufficient time for personal life. The majority of residents (69.7%) indicated that they would choose the same residency program again, but 12.2% would have made a different choice. Almost three-fourths of residents (73.0%) felt that faculty and staff cared about the educational success of residents, but 9.27% did not. Binomial multivariable regression revealed that senior residents (odds ratio: 6.70; 95% confidence interval, 2.20-22.4) were more likely to desire a different residency program. In contrast, residents who reported constructive feedback use by the residency program (odds ratio:0.22; 95% confidence interval, 0.06-0.91) were more satisfied with their program choice. CONCLUSIONS: Most RO residents reported satisfaction with their choice of residency program, but seniors had higher rates of dissatisfaction. Possible interventions to improve professional satisfaction include incorporating constructive resident feedback to enhance the program. The potential impact of job market pressures on seniors should be further explored.

Achieving gender equity in the radiation oncology physician workforce.

There is currently much interest in identifying and mitigating gender inequity within medicine, the greater workforce and society as a whole. We provide an evidence-based review of current and historical trends in gender diversity in the RO physician workforce and identify potential barriers to diversity and inclusion in training, professional development, and career advancement. Next, we move to actionable items, addressing methods to mitigate bias, harassment, and other impediments to professional productivity and characterizing leadership lessons and imperatives for departmental, institutional, and organizational leaders.

Meaningful and Accurate Disclosure of Conflict of Interest at the ASTRO National Meeting: A Need for Reassessment of Current Policies.

PURPOSE:: Conflict of interest (COI) disclosure is essential to research integrity. The average reading comprehension in English is 3.8 words per second (wps). This study examines presenters at the American Society for Radiation Oncology (ASTRO) national meeting over a recent 3-year period to determine whether disclosure is presented accurately and in a manner that allows the audience to comprehend the content. METHODS:: We examined videos of presentations as well as slides from 2014 to 2016 from the ASTRO virtual meeting, noting whether a COI slide was presented, the duration the slide was visible, and the number of disclosures. Disclosures were cross-referenced for discrepancies with the publicly reported Centers for Medicare and Medicaid Services Open Payments database. Using a cutoff of 4 wps, we noted how many presentations were presented at speeds of ≤ 4 wps and > 4 wps. RESULTS:: The final data set consisted of 401 presentations delivered by 364 presenters. Using a threshold of 4 wps, 34.0% of presenters had COI slides shown too fast for the average audience to comprehend. Moreover, 16.3% of US physicians incorrectly underreported industry funding received. Of these presentations with discrepancies, 32.6% did not have a COI slide, 39.5% failed to disclose any COI, 27.9% partially disclosed COIs, and 11.6% contained multiple discrepancies. The number of wps were correlated with having a discrepancy on multivariable regression ( P = .046; odds ratio, 1.08; 95% CI, 1.01 to 1.19). CONCLUSION:: A substantial minority of presentations at ASTRO lack meaningful disclosure, and a surprising number incorrectly reported COIs. Additional guidance may be needed to promote more meaningful and accurate disclosure of COIs at major national meetings in oncology.

Burnout Evaluation of Radiation Residents Nationwide: Results of a Survey of United States Residents.

PURPOSE: To assess rates of burnout among US radiation oncology residents and evaluate program/resident factors associated with burnout. METHODS AND MATERIALS: A nationwide survey was distributed to residents in all US radiation oncology programs. The survey included the Maslach Burnout Index-Human Services Survey (MBI-HSS) as well as demographic and program-specific questions tailored to radiation oncology residents. Primary endpoints included rates of emotional exhaustion, depersonalization, and personal accomplishment from MBI-HSS subscale scores. Binomial logistic models determined associations between various residency/resident characteristics and high burnout levels. RESULTS: Overall, 232 of 733 residents (31.2%) responded, with 205 of 733 (27.9%) completing the MBI-HSS. High levels of emotional exhaustion and depersonalization were reported in 28.3% and 17.1%, respectively; 33.1% experienced a high burnout level on at least 1 of these 2 MBI-HSS subscales. Low rates of personal accomplishment occurred in 12% of residents. Twelve residents (5.9%) reported feeling "at the end of my rope" on a weekly basis or more. On multivariable analysis there was a statistically significant inverse association between perceived adequacy of work-life balance (odds ratio 0.37; 95% confidence interval 0.17-0.83) and burnout. CONCLUSIONS: Approximately one-third of radiation oncology residents have high levels of burnout symptoms, consistent with previous oncology literature, but lower levels than those among physicians and residents of other specialties. Particularly concerning was that more than 1 in 20 felt "at the end of my rope" on a weekly basis or more. Targeted interventions to identify symptoms of burnout among radiation oncology residents may help to prevent the negative downstream consequences of this syndrome.

Industry Funding Among Leadership in Medical Oncology and Radiation Oncology in 2015.

PURPOSE: To quantify and determine the relationship between oncology departmental/division heads and private industry vis-à-vis potential financial conflict of interests (FCOIs) as publicly reported by the Centers for Medicare and Medicaid Services Open Payments database. METHODS AND MATERIALS: We extracted the names of the chairs/chiefs in medical oncology (MO) and chairs of radiation oncology (RO) for 81 different institutions with both RO and MO training programs as reported by the Association of American Medical Colleges. For each leader, the amount of consulting fees and research payments received in 2015 was determined. Logistic modeling was used to assess associations between the 2 endpoints of receiving a consulting fee and receiving a research payment with various institution-specific and practitioner-specific variables included as covariates: specialty, sex, National Cancer Institute designation, PhD status, and geographic region. RESULTS: The majority of leaders in MO were reported to have received consulting fees or research payments (69.5%) compared with a minority of RO chairs (27.2%). Among those receiving payments, the average (range) consulting fee was $13,413 ($200-$70,423) for MO leaders and $6463 ($837-$16,205) for RO chairs; the average research payment for MO leaders receiving payments was $240,446 ($156-$1,234,762) and $295,089 ($160-$1,219,564) for RO chairs. On multivariable regression when the endpoint was receipt of a research payment, those receiving a consulting fee (odds ratio [OR]: 5.34; 95% confidence interval [CI]: 2.22-13.65) and MO leaders (OR: 5.54; 95% CI: 2.62-12.18) were more likely to receive research payments. Examination of the receipt of consulting fees as the endpoint showed that those receiving a research payment (OR: 5.41; 95% CI: 2.23-13.99) and MO leaders (OR: 3.06; 95% CI: 1.21-8.13) were more likely to receive a consulting fee. CONCLUSION: Leaders in academic oncology receive consulting or research payments from industry. Relationships between oncology leaders and industry can be beneficial, but guidance is needed to develop consistent institutional policies to manage FCOIs.

Female Representation in the Academic Oncology Physician Workforce: Radiation Oncology Losing Ground to Hematology Oncology.

PURPOSE: Our purpose was to assess comparative female representation trends for trainees and full-time faculty in the academic radiation oncology and hematology oncology workforce of the United States over 3 decades. METHODS AND MATERIALS: Simple linear regression models with year as the independent variable were used to determine changes in female percentage representation per year and associated 95% confidence intervals for trainees and full-time faculty in each specialty. RESULTS: Peak representation was 48.4% (801/1654) in 2013 for hematology oncology trainees, 39.0% (585/1499) in 2014 for hematology oncology full-time faculty, 34.8% (202/581) in 2007 for radiation oncology trainees, and 27.7% (439/1584) in 2015 for radiation oncology full-time faculty. Representation significantly increased for trainees and full-time faculty in both specialties at approximately 1% per year for hematology oncology trainees and full-time faculty and 0.3% per year for radiation oncology trainees and full-time faculty. Compared with radiation oncology, the rates were 3.84 and 2.94 times greater for hematology oncology trainees and full-time faculty, respectively. CONCLUSION: Despite increased female trainee and full-time faculty representation over time in the academic oncology physician workforce, radiation oncology is lagging behind hematology oncology, with trainees declining in recent years in radiation oncology; this suggests a de facto ceiling in female representation. Whether such issues as delayed or insufficient exposure, inadequate mentorship, or specialty competitiveness disparately affect female representation in radiation oncology compared to hematology oncology are underexplored and require continued investigation to ensure that the future oncologic physician workforce reflects the diversity of the population it serves.

Trends in Disclosures of Industry Sponsorship.

PURPOSE: To examine trends in the reporting of industry funding of oncology trials by primary therapeutic intervention studied: local, targeted, or nontargeted systemic. METHODS AND MATERIALS: We reviewed oncologic trials published in 10 journals for the years 1994, 2004, and 2014 to determine the frequency of declarations of industry funding for cancer research. Logistic modeling was used to assess associations between reported industry funding and investigation characteristics, such as type of primary intervention, cancer site, study endpoint, number of participants, geographic location of corresponding author, journal impact factor, trial phase, and year of publication. RESULTS: Reporting of industry funding increased over time (odds ratio [OR] 6.8; 95% confidence interval [CI] 3.82-12.35). Compared with systemic trials, those investigating local therapies were less likely to report industry funding (OR 0.08; 95% CI 0.14-0.15), whereas studies examining targeted interventions were more likely to report industry funding (OR 2.24; 95% CI 1.38-3.66). Studies investigating gynecologic (OR 0.37; 95% CI 0.15-0.88) and pediatric cancers (OR 0.08; 95% CI 0.02-0.27) were less likely to report funding by industry when compared with hematologic cancers. Phase 2 (OR 0.32, 95% CI 0.19-0.52) and phase 3 (OR 0.39, 95% CI 0.17-0.37) studies were less likely to report industry funding than phase 1 studies. Trials investigating interventions for metastatic disease (OR 2.55; 95% CI 1.73-3.79) were more likely to have reported industry funding compared with studies examining the primary/definitive disease setting. CONCLUSION: Industry funding was reported in more than one-third of oncology trials examined in this study, and the proportion of trials reporting industry funding increased over time. The potential ramifications for these patterns of funding for the future direction of cancer research should be examined, especially given the disproportionate distribution of industry funding among therapeutic intentions, cancer types, and treatment modalities.

Close to Home: Employment Outcomes for Recent Radiation Oncology Graduates.

PURPOSE: To characterize the practice type and location of radiation oncology (RO) residents graduating in 2013. METHODS AND MATERIALS: Graduates completing RO residency in 2013 were identified, and for each, postgraduate practice setting (academic vs private practice) and location were identified. Characteristics of the graduates, including details regarding their institutions of medical school and residency education, were collected and analyzed. RESULTS: Data were obtained from 146 of the 154 RO graduates from the class of 2013. Employment data were available for 142 graduates. Approximately one-third of graduates were employed in the same state as residency (36.6%), approximately two-thirds (62.0%) in the same region as residency, and nearly three-fourths (73.9%) in the same region as medical school or residency completion. Of the 66 graduates (46.5%) working in academics, 40.9% were at the same institution where they completed residency. Most trainees (82.4%) attended medical schools with RO residency programs. CONCLUSIONS: Although personal factors may attract students to train in a particular area, the location of medical school and residency experiences may influence RO graduate practice location choice. Trends in the geographic distribution of graduating radiation oncologists can help identify and better understand disparities in access to RO care. Steps to improve access to RO care may include interventions at the medical student or resident level, such as targeting students at medical schools without associated residency programs and greater resident exposure to underserved areas.

Attracting Future Radiation Oncologists: An Analysis of the National Resident Matching Program Data Trends From 2004 to 2015.

PURPOSE: A significant physician shortage has been projected to occur by 2025, and demand for oncologists is expected to outpace supply to an even greater degree. In response to this, many have called to increase the number of radiation oncology residency positions. The purpose of this study is to evaluate National Resident Matching Program (NRMP) data for the number of residency positions between 2004 and 2015 as well as the number and caliber of applicants for those positions and to compare radiation oncology to all residency specialties. METHODS: NRMP data for all specialties participating in the match, including radiation oncology, were assessed over time examining the number of programs participating in the match, the number of positions offered, and the ratio of applicants to positions in the match from 2004 to 2015. RESULTS: From 2004 to 2015, the number of total programs participating in the match has increased by 26.7%, compared to the increase of 28.6% in the number of radiation oncology programs from during the same time period. The total number of positions offered in the match increased by 53.4%, whereas radiation oncology positions increased by 56.3%, during the same time period. The ratio of applicants (defined as those selecting a specialty as their first or only choice) to positions for all specialties has fluctuated over this time period and has gone from 1.21 to 1.15, whereas radiation oncology experienced a decrease from 1.45 to 1.14. CONCLUSIONS: NRMP data suggest that senior medical student applications to radiation oncology are decreasing compared to those of other specialties. If we hope to continue to attract the best and brightest to enter our field, we must continue to support early exposure to radiation oncology, positive educational experiences, and dedicated mentorship to interested medical students.

Does Cancer Literature Reflect Multidisciplinary Practice? A Systematic Review of Oncology Studies in the Medical Literature Over a 20-Year Period.

PURPOSE: Quality cancer care is best delivered through a multidisciplinary approach requiring awareness of current evidence for all oncologic specialties. The highest impact journals often disseminate such information, so the distribution and characteristics of oncology studies by primary intervention (local therapies, systemic therapies, and targeted agents) were evaluated in 10 high-impact journals over a 20-year period. METHODS AND MATERIALS: Articles published in 1994, 2004, and 2014 in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Lancet Oncology, Journal of Clinical Oncology, Annals of Oncology, Radiotherapy and Oncology, International Journal of Radiation Oncology, Biology, Physics, Annals of Surgical Oncology, and European Journal of Surgical Oncology were identified. Included studies were prospectively conducted and evaluated a therapeutic intervention. RESULTS: A total of 960 studies were included: 240 (25%) investigated local therapies, 551 (57.4%) investigated systemic therapies, and 169 (17.6%) investigated targeted therapies. More local therapy trials (n=185 [77.1%]) evaluated definitive, primary treatment than systemic (n=178 [32.3%]) or targeted therapy trials (n=38 [22.5%]; P<.001). Local therapy trials (n=16 [6.7%]) also had significantly lower rates of industry funding than systemic (n=207 [37.6%]) and targeted therapy trials (n=129 [76.3%]; P<.001). Targeted therapy trials represented 5 (2%), 38 (10.2%), and 126 (38%) of those published in 1994, 2004, and 2014, respectively (P<.001), and industry-funded 48 (18.9%), 122 (32.6%), and 182 (54.8%) trials, respectively (P<.001). Compared to publication of systemic therapy trial articles, articles investigating local therapy (odds ratio: 0.025 [95% confidence interval: 0.012-0.048]; P<.001) were less likely to be found in high-impact general medical journals. CONCLUSIONS: Fewer studies evaluating local therapies, such as surgery and radiation, are published in high-impact oncology and medicine literature. Further research and attention are necessary to guide efforts promoting appropriate representation of all oncology studies in high-impact, broad-readership journals.

Enoxaparin and Warfarin for Venous Thromboembolism Prophylaxis in Total Hip Arthroplasty: To Bridge or Not to Bridge?

Anticoagulation bridges consisting of subcutaneous enoxaparin combined with oral-dosed warfarin are commonly used in orthopedic procedures as chemoprophylaxis against thromboembolic disease. For some patients, these bridges result in complications. One hundred twenty-one patients were evaluated after primary total hip arthroplasty (THA) between 2008 and 2009. Sixty-three patients were given bridged therapy after THA, and 58 were given warfarin only. The 2 groups were statistically matched on various comorbidities. Outcomes of interest were number of days to dry wound and length of hospital stay. Wounds of patients given anticoagulation bridges took longer to heal than wounds of patients given warfarin only (odds ratio, 2.39; P < .05). In addition, patients given anticoagulation bridges had longer hospital stays (odds ratio, 1.27; P < .05). Compared with warfarin-only therapy after THA, use of warfarin bridged with enoxaparin increased the risk for prolonged wound healing and subsequent infection. In addition, bridged therapy cost $2000 more per patient than warfarin-only therapy. Further studies should examine the risks and benefits of these bridges in reducing thromboembolic disease.

Pregnancy and Parenthood in Radiation Oncology, Views and Experiences Survey (PROVES): Results of a Blinded Prospective Trainee Parenting and Career Development Assessment.

PURPOSE: Medical training spans nearly a decade, during which many physicians traditionally begin families. Although childrearing responsibilities are shared by men and women in the modern era, differences in time allocated to child care by sex and its potential impact on residency experience merit discussion. METHODS AND MATERIALS: An anonymous, voluntary, 102-item survey was distributed to 540 current radiation oncology residents and 2014 graduates that asked about marital and parental status, pregnancy during residency, publication productivity, career aspirations, and experiences working with pregnant co-residents. Respondents with children were asked about childcare arrangements, and women who were pregnant during residency were asked about radiation safety, maternity leave, and breastfeeding experiences. RESULTS: A total of 190 respondents completed the survey, 107 men (56.3%) and 84 women (43.7%). Ninety-seven respondents (51.1%) were parents, and 84 (44.2%) reported a pregnancy during residency. Respondents with children more often were male (65% vs 47.3%; P=.014), in a higher level of training (79.3% vs 54.8% were PGY4 or higher; P=.001), were older (median age of 32, interquartile range [IQR]:31-35] vs age 30 [IQR: 29-33]; P<.001), had a PhD (33% vs 19.3%, respectively; P=.033), were married (99% vs 43%, respectively; P<.001), and had a partner who did not work (24.7% vs 1.9%, respectively; <.001). There were no differences in the number of manuscripts published or the number of residents who expressed likelihood of pursing an academic career by parental status. Among parents, men more frequently had partners who did not work (38.1% vs 0%, respectively; P<.001) and reported that their partner performed a greater percentage of childcare duties (70% [IQR: 60%-80%] vs 35% [IQR: 20%-50%], respectively; P<.001). CONCLUSIONS: Pregnancy and parenthood are common during residency. Female residents are frequently responsible for more childcare duties than males but have similar research productivity and career aspirations. Further investigation is critical to elucidate gender disparities in parenthood and career development.